Provider Demographics
NPI:1205259694
Name:CLARK DENTAL GROUP
Entity type:Organization
Organization Name:CLARK DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-474-4292
Mailing Address - Street 1:3402 S 38TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-4638
Mailing Address - Country:US
Mailing Address - Phone:253-472-4292
Mailing Address - Fax:253-474-7708
Practice Address - Street 1:3402 S 38TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-4638
Practice Address - Country:US
Practice Address - Phone:253-472-4292
Practice Address - Fax:253-474-7708
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVIS CLARK, DDS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008552122300000X
WADE00006114122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty